冠心病合并2型糖尿病患者临床及血运重建特点分析

目的 分析冠心病合并2型糖尿病患者的临床和血运重建特点.方法 以2011年9月至2012年4月于天津市胸科医院心内科住院,并行冠状动脉造影确诊为冠心病的215例患者作为观察对象,分为2型糖尿病组77例和非糖尿病组138例,分析临床和冠状动脉血运重建特点.结果 与非糖尿病组比较:(1)2型糖尿病组合并高血压的患者比例较高(87.0％比74.6％,P＜0.05),三酰甘油水平较高[(2.03 ± 1.22) mmol/L比(1.65±0.78) mmol/L,P＜0.01],左心室射血分数较低(58.03％±9.80％比61.07％±7.35％,P＜0.05);(2)2型糖尿病组单支病变发生率低(16.9％比43.5％,P＜0.01),多支病变发生率高(39.0％比25.4％,P＜0.05);(3)两组患者血运重建策略差异有统计学意义,2型糖尿病组患者行冠状动脉旁路移植术者比例较高(17.2％比7.3％,P＜0.05),选择行经皮冠状动脉介入治疗者平均置入支架数目较多[(2.06±0.95)枚比(1.66±0.83)枚,P＜0.01].结论 冠心病合并2型糖尿病患者高血压及血脂异常的发生率高,冠状动脉病变严重且弥漫,血运重建方式更复杂.     

二代支架时代数据中糖尿病对无保护左主干患者不同血运重建术预后的影响

目的:在二代支架时代,糖尿病对不同血运重建策略治疗无保护左主干冠状动脉疾病患者的影响尚未可知。方法:回顾性入选823例无保护左主干冠状动脉疾病的患者,其中接受二代药物洗脱支架(DES)置入治疗的患者331例(糖尿病患者,n=99;非糖尿病患者,n=232),接受冠状动脉旁路移植术(CABG)患者492例(糖尿病患者,n=127;非糖尿病患者,n=365)。我们根据不同的血运重建策略比较了糖尿病对临床结果的影响。结果:在接受血运重建的无保护左主干病变患者中,糖尿病患者占27.5%(226/823)。经过平均25.3个月的随访后发现,在接受DES治疗的人群中,糖尿病患者与非糖尿病患者的全因死亡率、心源性死亡率、血运重建发生率、卒中和主要不良心脑血管事件的发生率没有显著差异。然而,在全因死亡/心肌梗死/卒中联合终点(糖尿病组21.5%vs.非糖尿病7.2%,P=0.001)及心肌梗死发生率(糖尿病组15.4%vs.非糖尿病组1.6%,P<0.001)中,糖尿病患者明显高于非糖尿病患者。在接受CABG治疗的群体中,糖尿病组和非糖尿病组所有临床终点发生率相似。结论:在二代药物洗脱支架治疗无保护左主干病变的患者中,合并糖尿病的患者较非糖尿病组预后较差,在接受CABG的患者中,糖尿病和非糖尿病组预后相似。     

分站式杂交技术治疗冠状动脉多支病变合并糖尿病患者的效果分析

目的比较分站式杂交(Hybrid)技术与非体外循环冠状动脉旁路移植术(OPCAB)治疗冠状动脉多支病变合并糖尿病(DM)患者的近中期临床效果。方法 2011年1月至2015年6月于郑州市第七人民医院共30例冠状动脉多支血管病变(包括前降支病变)合并DM患者接受了分站式Hybrid手术治疗,应用倾向性评分(Propensity score)方法,与同期实施孤立OPCAB的冠状动脉多支病变(包括前降支病变)合并DM患者相匹配,按1∶2比例选取60例患者,构成病例对照匹配样本。研究主要终点为患者随访期间的主要不良心脑血管事件(MACCE),次要终点为术后住院期间情况(包括24 h胸腔引流量、总引流量、红细胞输注率、呼吸机辅助时间、为控制出血的非计划二次手术、术后新发心房颤动等)。结果 Hybrid组术后24 h胸腔引流量、总引流量、呼吸机辅助时间和红细胞输注率均显著低于OPCAB组(均为P<0.05)。经过平均(22.0±8.4)个月的随访,Hybrid组与OPCAB组患者的MACCE(6.7%比11.7%)、全因死亡(0比1.7%)、心肌梗死(0比1.7%)及靶血管再血管化(6.7%比6.7%)发生率均相似(均为P>0.05),而Hybrid组的脑血管意外发生率显著减少(0比3.3%,P=0.037)。结论对于冠状动脉多支病变合并DM患者,分站式Hybrid技术是一种安全有效的冠状动脉再血管化治疗方式。     

一站式杂交技术与非体外循环下冠脉搭桥术治疗复杂冠心病的meta分析

目的用meta分析方法对一站式杂交技术与非体外循环下冠脉搭桥术治疗冠心病疗效的临床研究进行综合性定量研究。方法使用Cochrane系统评价方法,计算机检索EMBASE,Cochrane图书馆、中国知网、万方数据库、CBM,web of Science,scopus,Google scholar and Controlled Trails metaRegister,Pubmed及Medline等数据库的文献,收集有关比较一站式杂交技术和非体外循环下冠脉搭桥术治疗冠心病的对照研究实验,评价入选研究的质量。结果共纳入符合标准的文献5篇,共409例患者。Meta分析结果显示:杂交组手术时间长于传统组住院费用多于传统组(P0.05);机械通气时间、住ICU的时间住院时间失血量、输红细胞悬浮液量术后心肌梗死发生率明显低于传统组(P0.05)。杂交组的非计划再次手术、术后新发房颤发生率及随访期死亡发生率与传统组无统计学差异(P0.05),但是杂交组随访期主要心脏不良事件发生率低于传统组且重返工作或正常活动时间短于传统组(P0.05)。结论一站式杂交治疗复杂冠心病的疗效可能优于非体外循环下冠脉搭桥术。     

80岁以上冠心病患者血运重建的临床结果分析

目的评价年龄≥80岁的高龄冠心病患者血运重建治疗后的近期与远期临床结果 ,探讨远期不良事件的预测因素。方法选择接受冠状动脉血运重建治疗的冠心病患者(≥80岁)63例,记录其人口学资料、临床特征、冠状动脉造影和血运重建情况以及主要不良心脑血管事件(MACCE)。对所有患者进行电话或门诊随访,多因素Cox比例风险回归模型分析远期不良事件的预测因素。结果 85.7%的患者为多支病变。分别有81.0%和19.0%的患者接受PCI和冠状动脉旁路移植术(CABG)治疗,PCI成功率为98.0%,CABG成功率为83.3%,血管重建总成功率为95.2%。院内MACCE发生率为4.8%。中位随访时间为541(444～667)d,随访率为95.2%。总MACCE发生率为14.3%,病死率为11.1%;累积生存率为88.5%,累积无MACCE生存率为83.0%。多因素Cox分析,既往血运重建史、慢性完全闭塞病变以及是否循环支持是总MACCE的独立危险因素。结论年龄≥80岁的高龄冠心病患者接受血运重建治疗安全可行,成功率较高,院内不良事件发生率较低,远期生存率较高。     

Difference in the mortality of the CABRI diabetic and nondiabetic populations and its relation to coronary artery disease and the revascularization mode

In diabetics with coronary artery disease (CAD), there remains uncertainty as to whether revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG) is preferable. To address this, 4-year mortality and level of pre- and postrevascularization angiographic CAD (measured by a series of coronary scores) were compared between both diabetics and nondiabetics and between revascularization modes in the Coronary Angioplasty versus Bypass Revascularization Investigation population as a whole, and then substratified by diabetic status and then by procedure to which they were randomized. The 1,054 randomized subjects contained 125 diabetics (11.9%) who had significantly greater mortality than nondiabetics (RR 2.19, p = 0.001). Among diabetics or nondiabetics, there was no significant mortality difference between those randomized to PTCA versus those to CABG. Diabetics randomized to PTCA and those to CABG had higher mortalities than respective nondiabetics; the association reached significance only in the former (RR 2.41, p = 0.002). All subgroups had similar prerevascularization CAD. Postrevascularization residual CAD was consistently significantly greater in PTCA than in respective CABG subgroups. Most measurements of CAD were greater in diabetic than in nondiabetic subgroups, but none was significant. In the Coronary Angioplasty versus Bypass Revascularization Investigation, diabetics had double the mortality of nondiabetics; this difference was statistically significant both for the entire population and for those randomized to PTCA, but not for those randomized to CABG. Among diabetics or nondiabetics, there was no significant mortality difference between PTCA and CABG. The higher diabetic mortality was more likely related to more rapid disease progression than to greater postrevascularization disease.     

Origin and length of left main coronary artery: Its relation to height,weight, sex,age, pattern of coronary distribution,and presence or absence of coronary artery disease

The distance from the base of the left coronary sinus to the origin of the left main coronary artery was measured in 54 patients. The length of the left main coronary artery and the pattern of arterial dominance were determined in the last 37 patients. These variables were correlated with height, weight, age, sex, and presence or absence of coronary artery disease. Average distance from the base of the left coronary sinus to the origin of the left main coronary artery was 19.4 ± 2.7 mm. Average length of the left main coronary artery was 9.7 ± 4.3 mm. There was a large inherent variability between distance from the base of left coronary sinus to the origin of the left main coronary artery and height of the subjects. Other variables did not show positive correlation. Similar large variability was noticed between length of the left main coronary artery and height of the subjects. Thus, from these observations it was not possible to predict the distance from the base of the left coronary sinus to the origin of the left main coronary artery or the length of the left main coronary artery using height or any other variable. The importance of these findings in relation to coronary angiography is discussed.     

Coronary calcium detected by digital cinefluoroscopy and coronary artery disease in patients undergoing coronary arteriography: effects of age and sex

BACKGROUND: Coronary artery calcium, detected non-invasively, correlates well with angiographically documented coronary artery disease (CAD). This study was conducted to evaluate the diagnostic efficacy of coronary artery calcium detected by digital cinefluoroscopy for CAD and assess the effects of age and sex on it. METHODS: In 242 patients who underwent coronary angiography, coronary calcium status was determined and related to angiographic findings. RESULTS: Calcium detection had a sensitivity 85%, specificity 52%, positive predictive value 92%, negative predictive value 33% and diagnostic accuracy 81% for significant CAD. There was a better positive predictive value in men (95% vs. 80%) and negative predictive value in women (65% vs. 16%), while a higher sensitivity and diagnostic accuracy was found in older than in younger (90% and 86% vs. 78% and 74%). The sensitivity of the method increased with the number of the diseased vessels. CONCLUSIONS: Coronary calcium can be quite accurately detected by digital cinefluoroscopy. This, however, should be made in the context of sex and age.     

Kawasaki disease, myocardial infarction and coronary artery revascularization

Kawasaki disease (KD) is the leading cause of acquired pediatric heart disease in North America and Japan. Cardiac sequelae, such as coronary artery aneurysms and myocardial infarction, are the major causes of the morbidity and mortality associated with KD. Three case scenarios are described illustrating the wide range of clinical presentations of myocardial ischemia in children after acute KD, varying from asymptomatic to fatal myocardial infarction. In addition, the present paper provides a review of the literature on myocardial infarction in association with KD and various modalities of coronary artery revascularization in children with myocardial ischemia secondary to KD.     

肾动脉狭窄并冠状动脉多支病变患者部分或完全冠状动脉血运重建对比分析

目的 探讨在肾动脉狭窄合并冠状动脉粥样硬化性心脏病（冠心病）的患者中进行冠状动脉介入治疗时,选择部分或完全冠状动脉血运重建方法的临床效果差异.方法 收集2006年1月至2011年1月在广东省人民医院进行肾动脉及冠状动脉介入治疗的肾动脉狭窄合并冠心病患者共287例,其中177例进行了冠状动脉完全血运重建（complete revascularization,CR）,110例为部分冠状动脉血运重建（incomplete revascularization,ICR）.然后进行术后2年的随访调查,比较两种介入治疗策略的临床疗效以及其远期预后的差异.结果 两种治疗策略的整体住院病死率比较,差异无统计学意义（Х^2=0.474,P=0.491）.术后CR组的收缩压及舒张压较基线降低,差异有统计学意义（P均＜0.01）;而ICR组收缩压及舒张压与基线相比,差异无统计学意义（P＞0.05）.两组术前和术后肾功能、心功能改善的情况及住院时间比较,差异无统计学意义（P均＞0.05）.两组2年随访病死率及主要心血管事件发生率比较,差异无统计学意义（P均＞0.05）.结论 肾动脉狭窄患者在进行肾动脉及冠状动脉介入治疗时,进行冠状动脉完全血运重建和部分冠状动脉血运重建术效果相近,但完全血运重建有助于血压的控制.     

Seasonal onset of insulin dependent diabetes in relation to sex and age at onset

Summary All newly diagnosed insulin dependent diabetics presenting consecutively to the Diabetic Department of the Royal Infirmary from the City of Edinburgh or its environs, between the years 1964 and 1977, were analysed for sex (297 males, 205 females), age at diagnosis (range 10–75 years), month of diagnosis, duration of symptoms and month of symptomatic onset. Males aged 10–19 years showed a significant seasonal variation in diagnosis (p<0.025) with an increase in autumn and winter months which was not seen in females aged 10–19 years nor in patients of either sex aged more than 19 years at diagnosis. The duration of diabetic symptoms increased with increasing age at diagnosis in both males and females and was consistantly greater in females than in males for each age group at diagnosis. When the month of symptomatic onset was considered in relation to sex and age at diagnosis, having excluded patients with duration of symptoms of more than three months, only males aged 10–19 years at diagnosis showed a significant seasonal variation in incidence (p<0.005).     

分站式杂交技术与非体外循环冠状动脉移植术治疗冠状动脉多支病变的对比研究

目的:比较分站式杂交(Hybrid)技术与非体外循环冠状动脉搭桥术(off-pump coronary artery bypass grafting,OPCAB)治疗冠状动脉多支病变患者的近中期临床结果。方法:选取2011年1月至2014年10月,共26例包括冠状动脉前降支病变在内的多支血管病变患者接受分站式杂交手术治疗,同期665例实施OPCAB,均为包含前降支病变在内的冠状动脉多支病变患者。应用倾向性评分(propensity score)方法,按1:l比例匹配26例患者与分站式复合技术组患者进行配对,分为Hybrid技术组和OPCAB组。研究终点为患者随访期间的无主要心脑血管不良事件(major adverse cardiac and cerebrovascular event,MACCE)生存率。结果:两组患者术前主要临床资料和冠状动脉造影资料差异无统计学意义;两组患者均有前降支病变。分站式杂交技术组的胸腔引流量(498±206)m L,呼吸机辅助时间[(3.5±0.5)小时,平均ICU滞留时间为22.5小时,均相应低于OPCAB组分别为:(988±88)m L,P=0.02;9.6小时,P=0.035,(48.6±8.6)小时,P=0.01]。经过平均(18±9.2)个月的随访,Hybrid组与OPCAB组相比MACCE发生率差异无统计学意义(P=0.25)。结论:分站式杂交技术在更小的创伤下,获得了与常规OPCAB相近的近中期临床效果。     

Beta-blockers: recognising the assets in relation to coronary artery disease

Beta-blockers have been shown to reduce the risk of coronary events and reduce the mortality of patients with hypertension and in those who have had a myocardial infarction. Furthermore, the evidence for long-term benefits in these two patient groups are much more convincing for beta-blockers than for other therapeutic agents used to treat these patient groups. In spite of this beta-blockers are underused because doctors believe that these drugs are contraindicated in many vulnerable patient groups. The data now available from the many trials and observational studies have shown that patients such as the elderly, those with some degree of heart failure, diabetics and those with chronic lung disease not only tolerate beta blockers but derive more benefit than more healthy patient groups.     

Choosing a revascularization strategy in patients with diabetes and stable coronary artery disease: a complex decision

Diabetes mellitus is associated with well-known increases in cardiovascular morbidity and mortality. In diabetics with stable coronary artery disease, the best therapeutic option is widely discussed. Current studies comparing surgical to percutaneous revascularization have been unable to definitely demonstrate any significant advantage of one strategy over the other regarding the prevention of cardiac death or acute myocardial infarction. Therefore, even taking into account clinical and angiographic information as well as the risks determined by each type of treatment, the decision regarding the best therapeutic strategy in diabetics with stable coronary artery disease is still complex.     

Smoking in Saudi Arabia and its relation to coronary artery disease

Objectives

The health hazards related to smoking are well known. Smoking is a recognized risk factor for coronary artery disease (CAD). Despite rejection of smoking by the Saudi community, we are still seeing smokers in our population. This study is designed to determine the prevalence of smoking in the Kingdom of Saudi Arabia (KSA), and to find out its relation to CAD. This study is part of the Coronary Artery Disease In Saudis (CADIS) study.

Methods

This health survey was conducted by collecting data regarding smoking status among adult Saudis aged between 30 and 70 years of both sexes in KSA over a five year period from 1995 up to 2000. The study sample was of normal distribution and representative of all regions of KSA. The data were analyzed to provide the prevalence of smoking and its relation with CAD.

Results

The total number of subjects was 17,350, and current smokers were 2217; accordingly the overall prevalence of smoking among Saudis was 12.8%. Males (1555) were significantly smoking more than females (662) with a prevalence of 18.7% and 7.3%, respectively (P < 0.0001). Smoking is more prevalent among Saudis living in urban, northern, western, and eastern regions compared to other regions of KSA. Smokers are more likely to develop CAD compared to non-smokers (P < 0.0001).

Conclusions

Smoking is a prevalent health problem among Saudis that requires intervention for eradication. We found clear association between cigarettes smoking and CAD particularly among males. Persistent education of the health hazards related to smoking is recommended particularly at early age in-order to prevent initiation of smoking.     

Physicians' judgments of survival after medical management and mortality risk reduction due to revascularization procedures for patients with coronary artery disease

STUDY OBJECTIVE:s: To assess the accuracy of physicians' judgments of survival probability for medically managed patients with coronary artery disease (CAD), and of the absolute risk reduction of mortality due to coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for such patients; and relationships among these judgments and the physicians' propensity to perform revascularization. DESIGN: Two surveys (for three-vessel or two-vessel CAD) for patients presenting with stable CAD, currently managed medically, and without other life-limiting problems. SETTING: Multiple educational conferences, 1996-1997. PARTICIPANTS: Conference attendees. MEASUREMENTS AND RESULTS: Main outcomes were proportions of patients for whom the physicians would recommend revascularization (CABG for three-vessel CAD, CABG or PTCA for two-vessel CAD), and judgments of the proportions of medically managed patients who would be alive after 5 years, 7 years, and 11 years, and of absolute risk reduction of mortality due to CABG (or PTCA for two-vessel CAD). At least one half of the participants judged the survival rate of medically managed patients with three-vessel or two-vessel CAD to be less than the lowest rates supported by the best available evidence. More than one fourth judged the absolute risk reduction due to CABG to be higher than the highest values based on such evidence. Physicians' propensity to perform revascularization correlated inversely with their judgments of survival given medical management, and with their judgments of absolute risk reduction due to revascularization. CONCLUSIONS: Physicians may overuse revascularization because of excessive pessimism about survival of medically managed patients, and excessive optimism about the survival benefits of revascularization.     

Race and sex differences in the management of coronary artery disease

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decision-making appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician awareness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.